Electronic Trading Partner Profile

Electronic Trading Partner Profile

& Transmission Profile – Sender’s Response

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Receiver Name: Maine Workers' Compensation Board Fax: 207-287-7198

Attention: Paul J. Fortier Phone: 2027-287-3818

Address: State House Station 27, Augusta, Maine 04333-0027

Email:

Master Trading Partner Information

Sender Legal Name (no abbreviations): ______

Sender ID: The Federal Employer's Identification Number of your business entity. This, along with the 9 position Postal Code (Zip+4), will be used to identify a unique trading partner. The Sender ID FEIN and Postal Code should be the same as those that will be used by the partner as the Sender ID in the Header Record of all EDI transmissions from the partner:

Sender ID – FEIN:______Postal Code (9 digits): ______

Sender Trading Partner Type (check all that apply):

__ Jurisdiction __ Claim Administrator

__ Insurer __ Self-Insurer

__ Employer __ EDI Service Provider

__ Other (specify) ______

Physical Address:

Address Line 1 ______

Address Line 2 ______

City: Columbus______State: ______Postal Code: ______

Mailing Address:

Address Line 1 ______

Address Line 2 ______

City: ______State: ______Postal Code: [_____] + [ ]

Contact Information:

Business Contact Technical Contact

Name: Name:

Title: Title:

Phone: Phone:

FAX: FAX:

E-mail: E-mail:

Transaction Information

Secure File Transfer Protocol (FTP/SSL):

*The State uses a secure FTP (FTP/SSL). Once this document has been submitted, a login name and password will be forwarded to the Technical Contact identified above. Network communication testing can begin at any point after the login information has been sent to the Claim Administrator. Some products that are currently being used for FTP/SSL are FileZilla v 2.2.23a and WS FTP Pro.

Electronic Trading Partner Profile

MAINE ELECTRONIC TRANSMISSION PROFILE

RECEIVER'S SPECIFICATIONS

For Trading Partner’s Info

Receiver Type: Jurisdiction

Receiver ID - FEIN: 521609433 Postal Code (9 digits): 043330027

Transaction Information Acknowledgment Information

CLAIMS R3.0

Claims FROI (148/R21) R3 Flat File AKC

Claims SROI (A49/R22) R3 Flat File AKC

Coverage POC R2.1

Coverage PC-1 R2.1 Flat File AKP

Coverage PC-2 R2.1 Flat File AKP

Transmission Frequencies

Available Submission Times Sunday – Saturday (24/7)

File Processing Monday – Friday 6 am, 10 am, and 2 pm EST

Acknowledgement Retrieval Times Monday – Friday 7:30 am, 11:30 am, and 3:30 pm EST

(May be earlier depending on volume of files/transactions sent)

Jurisdiction Approved Transmission Method: FTP Only

File Transfer Protocol (FTP)

Specifications Receiver Requirements

IP Address: 198.182.163.91

Port: 21

Password: *see below

*(login name and Password will be provided upon receipt of this form)

Maine Contact: Maine Workers' Compensation Board

Attention: Paul J. Fortier, Agency Technology Officer

Address: State House Station 27, Augusta, Maine 04333-0027

Phone: (207) 287-3818 Fax: 207-287-7198

Email: